The patient presents with a chief complaint of severe headache and blurred vision for the past three days.

QUESTION

problem-focused SOAP note for grading. You must use an actual patient from your clinical practicum who presents with one or more chief complaints.

Use the format below for your SOAP note.

Use the current APA format to style your paper and cite your sources. Review the rubric for more information on how your assignment will be graded.

Problem-focused SOAP Note Format

Demographic Data

• Age, and gender (must be HIPAA compliant)

Subjective

• Chief Complaint (CC): A short statement about why they are there
• History of Present Illness (HPI):  Write your HPI in paragraph form. Start with the age, gender, and why they are there (example: 23-year-old female here for…). Elaborate using the acronym OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment
• Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance
• Family Hx: any history of CA, DM, HTN, MI, CVA?
• Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
• Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)

Objective

• Vital Signs
• Physical findings listed by body systems, not paragraph form- Highlight abnormal findings

Assessment (the diagnosis)

• At least Two (2) differential diagnoses (if applicable) with rationale and pertinent positives and negatives for each
• Final diagnosis with rationale, pertinent positives and negatives, and pathophysiological explanation

Plan

• Dx Plan (lab, x-ray)
• Tx Plan (meds): including medication(s) prescribed (if any), dosage, frequency, duration, and refill(s) (if any)
• Pt. Education, including specific medication teaching points
• Referral/Follow-up
• Health maintenance: including when screenings eye, dental, pap, vaccines, immunizations, etc. are next due

Reference

•  APA format- Compare care given to the patient with the National Standards of Care/National Guidelines. Cite accordingly.

ANSWER

Demographic Data:
Patient’s Age: 45
Gender: Female

Subjective

Chief Complaint (CC):
The patient presents with a chief complaint of severe headache and blurred vision for the past three days.

History of Present Illness (HPI)

A 45-year-old female presents to the clinic with a chief complaint of severe headache and blurred vision that started three days ago. The headache is located in the frontal region and is described as throbbing in nature. The patient reports that the headache has been constant and worsens with any movement. She rates the pain as 8 out of 10 on the pain scale. The patient denies any history of trauma or recent illness. She also reports experiencing blurred vision, especially when looking at bright lights. There are no alleviating factors, and over-the-counter pain medications have provided minimal relief. The patient denies any previous episodes of similar headaches or migraines.

Past Medical History (PMH)

The patient’s past medical history is significant for hypertension, which is well-controlled with antihypertensive medication. She has no history of surgeries, allergies, or immunizations. Her last health maintenance check-up, including eye and dental examinations, was six months ago.

Family History

The patient’s family history is negative for any history of cancer, diabetes mellitus, hypertension, myocardial infarction, or stroke.

Social History

The patient works as a teacher and reports mild-to-moderate stress due to her profession. She exercises regularly and follows a balanced diet. The patient denies any history of substance use or sexual health concerns.

Review of Systems (ROS)

Cardiovascular: No chest pain or palpitations.
Respiratory: No shortness of breath or cough.
Gastrointestinal: No nausea, vomiting, or diarrhea.
Musculoskeletal: No joint pain or swelling.
Neurological: Reports headaches and blurred vision.
Psychiatric: Denies any history of anxiety or depression.

Objective

Vital Signs

Blood Pressure: 128/82 mmHg
Heart Rate: 76 bpm
Respiratory Rate: 16 breaths per minute
Temperature: 98.6°F (oral)
Oxygen Saturation: 98% on room air

Physical Findings

General: The patient is alert, oriented, and in no acute distress.
Head: No signs of trauma or abnormal findings on palpation.
Eyes: Pupils are equal and reactive to light. Fundoscopic examination reveals no abnormalities.
Neurological: Cranial nerves II-XII intact. No motor or sensory deficits.

Assessment (Diagnosis)

Differential Diagnoses

Migraine Headache: Based on the patient’s description of the headache as throbbing, associated with photophobia, and worsened by movement.
Hypertensive Headache: Due to the patient’s history of well-controlled hypertension, it is essential to consider hypertension-related headaches as a differential diagnosis.

Final Diagnosis

Migraine Headache: The patient’s symptoms, including severe throbbing headache with photophobia and exacerbation with movement, are consistent with a migraine headache. The absence of any neurological deficits or abnormal physical findings suggests a primary headache disorder.

Plan

Diagnostic Plan

Complete Blood Count (CBC) and comprehensive metabolic panel (CMP) to assess for any underlying metabolic or inflammatory conditions.
Head CT or MRI to rule out any structural abnormalities in the brain.

Treatment Plan

Symptomatic relief with over-the-counter analgesics like ibuprofen or acetaminophen.
Lifestyle modifications: Encourage stress reduction techniques and adequate hydration.
Patient Education: Provide information on migraine triggers, symptom management, and when to seek immediate medical attention.
Follow-up: Schedule a follow-up visit in one week to assess the patient’s response to treatment and evaluate any new symptoms.

Health Maintenance

Recommend eye examination in six months and dental examination in one year.